NDEP

MED

ICIN

ESK

IDN

EY/H

EAR

T &

VA

SCU

LAR

FEET

EYES

MO

UTH

From: To:

Patient Information:

Name: __________________________________________________________ DOB: __________________________________________

Diabetes: qType 1 qType 2 qGestational qPrediabetes HbA1c Goal: ______ q< 6 months q>/= 6 months qUnknown

Duration of Diabetes (in years): ______ Current Diabetes Therapy: q Insulin qOral Hypoglycemic qDiet Control qNone Results of Last Finger-stick blood glucose reading (per patient): ______ qN/A Patient reports under control qYes q No

Dietary Counseling qYes q No Type of Diet: _________________________________________________________________________

Date: _______________ Patient has a written med list qYes q No OTC Meds Used: (if none: q )Herbal Meds Used: (if none: q )Pharmacist reviewed meds on (date): ______Patient has Rx for: (provide reason if “no”) Aspirin qYes q No:Cholesterol med qYes q No:ACE inh or ARB qYes q No:

Reports Side Effects to Meds qYes q No If yes, describe:Reports hypoglycemia events? qYes q No If yes, describe:

Does patient know their current:A1c? qYes q No Goal A1c?: qYes q No LDL? qYes qNo Goal LDL? qYes q No BP? qYes q No Goal BP? qYes qNo

Home Glucose Monitoring Frequency: qonce dailyq twice daily q3-4 times dailyqOther: _____________ If on insulin, list current dose:

List dosing times:

Date: _______________ Risk factors in addition to diabetes:(give dates for all)Blood Pressure: Goal:_____ Measured: _____Total, LDL and HDL cholesterol,triglycerides: (LDL goal and measured values for all)_____________________________________

_____________________________________

Smoking status: (circle all that apply)Never Former Current Willing To QuitAssessments: (give dates for all)Urine albumin-to-creatinine ratio: _ _ Serum creatinine and estimated GFR: _________________________________ __

Potassium: _______________________ _

Hemoglobin: ____________________ ___

History of myocardial infarction, heart failure, or stroke: ___________ Heart or brain testing (e.g. stress test, echo, angiogram, CT scan, ultrasound, MRI): _________________________ _History of dialysis or kidney transplant:_______________________________Kidney tests (ultrasound, CT Scan, Angiogram):___________________

Date: _______________ Current ulcer or history of a foot ulcer? qYes q NoFoot Exam: Skin, Hair, and Nail ConditionIs the skin thin, fragile, shiny and hairless? qYes q No Are the nails thick, too long, ingrown, or infected with fungal disease? qYes q No

Note Musculoskeletal DeformitiesqToe deformities qBunions (Hallus Valgus) qCharcot foot qFoot drop qProminent Metatarsal Heads

Pedal Pulses - “P” for present or “A” for absentPosterior tibial Left__ Right__ Dorsalis pedis Left__Right__

Risk Categorization check appropriate box.qLow Risk Patient qHigh Risk PatientAll of the following: One or more of the following:q Intact protective sensation qLoss of protective sensationqPedal pulses present qAbsent pedal pulsesqNo deformity qFoot deformityqNo prior foot ulcer qHistory of foot ulcerqNo amputation qPrior amputation

Date: _______________ Visual Acuity (best corrected) Right:________ Left:________ Intraocular Pressure Right:________ Left:________qDilated Fundus Exam Performed

Diagnosis:No Diabetic Retinopathy qYes q NoNon-Proliferative Diabetic Retinopathy qYes q No

Plan:qMonitor Only q Repeat Dilated Exam In _______ monthsqAdditional Testing/Treatment Recommended:

Proliferative Diabetic Retinopathy qYes q No Clinically Significant Macular Edema qYes q No

Date: _______________ Examination FindingsIntraoral/Extraoral: Xerostomia:Caries: Fungal infection:Periodontal (health, abscesses, gingivitis, periodontitis): Parotid gland changes:Functional (eating, swallowing, etc) concerns: ______________________________________________________________________Additional Testing/Treatment Recommended: ______________________________________________________________________Refer to Specialist: _____________________________________________ Re-evaluate in _________months(s)

Management:qFollow-up:__________ months qPatient education/discussion q Information pamphlet givenReferral To:_____________________________________ For:______________________________________________________________Other_______________________________________________ Doctor’s Signature_____________________________________________

Diabetes Head to Toe Checklist Examination ReportYour organization’s name here____________________________